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Journal of the American Academy of Orthopaedic Surgeons
56
Metastatic disease is the leading
cause of death in cancer patients.
Bone is the third most common site
of metastatic disease, after lung and
liver. Tumors of breast, thyroid,
lung, prostate, and kidney origin
are the most likely to metastasize to
bone. Of the estimated 1.2 million
new cases of cancer diagnosed,
more than one half will be osteo-
philic tumors (i.e., breast, lung and
prostate cancer).
1
Furthermore, by
the time of death, more than 50% of
patients with these tumors will
have had metastases to bone. Im-
provements in oncologic manage-
ment of patients with metastatic
disease have resulted in increased
duration of survival. As a result,
orthopaedic surgeons are being
asked more frequently to evaluate
and treat the skeletal manifestations
of metastatic disease.
Virtually any primary malignant
tumor can metastasize to bone, and
any bone may be involved. How-
ever, metastatic lesions most typi-

cally occur in the spine, pelvis,
femur, ribs and skull. In most cases,
there are multiple sites of involve-
ment. Large impending lesions or
actual pathologic fractures often
result in forced immobilization due
to severe pain and account for as
many as 60% of orthopaedic proce-
dures performed on patients with
metastatic disease.
2
Most femoral
lesions involve the proximal third.
However, this review will discuss
the evaluation and treatment of
metastatic disease in any portion of
the femur.
Clinical Presentation
Pain is the most common present-
ing symptom of metastatic disease
(both solid tumors and hematologic
malignant conditions). In a study of
87 patients with breast cancer, 32 of
the 33 patients who had osseous
metastases had bone pain.
3
In a
study of 536 patients with multiple
myeloma, bone pain was reported
in more than two thirds.

4
Al-
though the mechanism responsible
for causing bone pain remains
incompletely understood, it is
thought to be the result of stretch-
ing of the periosteum by increasing
tumor size or stimulation of nerve
endings in endosteal bone. The
symptoms of metastases in the
lower extremity range from a dull
ache to a deep-seated, intense pain.
Dr. Swanson is Resident, Department of
Orthopaedic Surgery, Mayo Clinic, Rochester,
Minn. Dr. Pritchard is Professor of Ortho-
paedic Surgery and Consultant, Mayo Clinic,
Rochester. Dr. Sim is Professor of Orthopaedic
Surgery and Consultant, Mayo Clinic,
Rochester.
Reprint requests: Dr. Pritchard, Mayo Clinic,
200 First Street SW, Rochester, MN 55905.
Copyright 2000 by the American Academy of
Orthopaedic Surgeons.
Abstract
Nearly every malignant neoplasm has been described as having the capability to
metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed
annually, more than 50% will eventually demonstrate skeletal metastasis.
Advances in systemic and radiation therapy have led to a considerable improve-
ment in the prognosis of patients with metastatic disease. As a result,
orthopaedic surgeons are being asked with increasing frequency to evaluate and

treat the manifestations of skeletal metastases. The femur is commonly the site
of large impending lesions and complete pathologic fractures. Although the
health status of some patients may preclude operative intervention, established
pathologic fractures of the femur and metastatic lesions deemed likely to
progress to imminent fracture generally should be treated surgically. A ratio-
nal approach to selection of the proper treatment for these problems includes
consideration of the patientÕs overall medical condition and the type, location,
size, and extent of the tumor. Treatment principles are the same regardless of
location. A construct should ideally provide enough stability to allow immedi-
ate full weight bearing with enough durability to last the patientÕs expected life-
time. All areas of weakened bone should be addressed at the time of surgery in
anticipation of disease progression. To minimize disease progression and possi-
ble implant or internal fixation failure, postoperative external-beam irradiation
should be considered.
J Am Acad Orthop Surg 2000;8:56-65
Surgical Treatment of Metastatic Disease of the Femur
Kyle C. Swanson, MD, Douglas J. Pritchard, MD, and Franklin H. Sim, MD
Kyle C. Swanson, MD, et al
Vol 8, No 1, January/February 2000
57
Weight bearing may precipitate
severe discomfort as a result of
microscopic buckling.
5
Night pain
and pain at rest are also cardinal
features at presentation.
A pathologic fracture, most com-
monly of the femur,
6

may be the
first presenting sign of metastatic
disease. Approximately two thirds
of all long-bone pathologic frac-
tures occur in the femur.
7
Most
(50%) involve the proximal femur,
with 20% involving the intertro-
chanteric region, and the remainder
occurring in the subtrochanteric,
diaphyseal, and supracondylar re-
gions.
The incidence of pathologic frac-
ture of the femur is quite variable,
depending on tumor type, location,
and histologic characteristics. Breast
cancer accounts for most pathologic
fractures, but a large percentage of
renal cell carcinomas and thyroid
cancers cause pathologic fracture as
well, due to the lytic nature of the
bone involvement. In one study of
180 pathologic fractures in 157
patients, 130 fractures were sec-
ondary to breast, lung, or prostate
carcinoma.
8
Habermann et al
9

eval-
uated 283 pathologic fractures and
23 impending fractures of the
femur. Metastatic disease from four
types of primary tumors accounted
for 85% of the fractures (breast, 56%;
kidney, 11%; multiple myeloma,
9.5%; lung, 8.5%).
9
Only 11 (3.6%)
of the 306 pathologic and impend-
ing fractures were due to prostate
cancer. Although the incidence of
prostate cancer is relatively high
and its metastatic spread is almost
universally to bone, it infrequently
causes pathologic fracture. This
may be related to its blastic, rather
than lytic, nature.
Clinical Evaluation
Proper evaluation of a patient with
metastatic disease begins with a
thorough history and physical
examination. For patients present-
ing with no prior history of malig-
nancy, salient historical points
include characterization of pain,
weight loss, and decline in activity
level. Prior history of malignancy
should heighten clinical suspicion.

The location of the pain usually
directs the physical examination,
although metastases that involve
joints or periarticular bone may pro-
duce symptoms (referred pain) sim-
ilar to those of arthritis. With in-
volvement of the femur in the hip
and thigh region, swelling and soft-
tissue masses are rarely detectable.
Laboratory evaluation is seldom
diagnostic in the workup of meta-
static disease because there is no
single specific marker of bone
metastasis. However, disturbances
in normal metabolic and hemato-
logic variables can aid in the diag-
nosis of a primary or secondary
disorder associated with a patho-
logic process.
Hypercalcemia is a common met-
abolic complication of metastatic
disease. In a study of 498 patients
with breast cancer, hypercalcemia
was noted in 86 patients (17%) on first
recurrence in bone. Unrecognized, it
can be the source of significant mor-
bidity. Serum calcium levels be-
tween 2.9 and 3.1 mmol/L (11.5 to
12 mg/dL) may cause unpleasant
side effects related to dysfunction of

the gastrointestinal tract, kidneys,
and central nervous system. When
calcium levels exceed 3.2 mmol/L
(13 mg/dL), renal insufficiency and
calcification in kidneys, skin, blood
vessels, lungs, heart, and stomach
may occur, particularly if blood
phosphate levels are normal or ele-
vated due to impaired renal func-
tion. Severe hypercalcemia, usually
defined as a calcium level of 3.7
mmol/L (15 mg/dL) or above, is a
medical emergency. Death may
ensue as a result of cardiac arrhyth-
mias and renal failure.
10,11
When there is evidence of meta-
static disease and no primary tu-
mor has been identified, the patient
should undergo biochemical screen-
ing for multiple myeloma. This in-
cludes a complete blood cell count,
erythrocyte sedimentation rate, and
serum protein electrophoresis.
Approximately 70% of patients
with multiple myeloma are anemic,
and approximately 65% have an ele-
vated sedimentation rate.
12
When

adenocarcinoma is suspected, it
may be reasonable to evaluate tu-
mor markers, such as α-fetoprotein,
β-human chorionic gonadotropin,
carcinoembryonic antigen (associ-
ated with ovarian and breast can-
cer), and prostate-specific antigen.
However, because of the lack of
specificity, the value of these mark-
ers generally resides in assessment
of response to therapy, rather than
identification of the primary site, in
a patient with metastatic disease.
Rougraff et al
13
have outlined a
successful diagnostic strategy
aimed at identification of the pri-
mary malignant tumor in patients
who have skeletal metastases of
unknown origin. Evaluation con-
sists of a history, physical examina-
tion, routine laboratory analysis,
plain radiography of the involved
bone and the chest, whole-body
technetium-99m bone scintigraphy,
and computed tomography (CT) of
the chest, abdomen, and pelvis. In
34 of their 40 patients (85%), the
primary site was identified. Labo-

ratory values were found to be
nonspecific in all cases. The history
and physical examination revealed
the occult primary site of the
malignant tumor in 3 patients (8%).
Plain radiographs of the chest were
diagnostic of lung carcinoma in 17
patients (43%). An additional 6
(15%) primary lung carcinomas
were identified with CT of the
chest. Computed tomography of
the abdomen and pelvis estab-
lished the diagnosis in 5 patients
(13%). Although tissue biopsy
alone was diagnostic in 3 patients
(8%), it was not useful in identify-
Surgical Treatment of Metastatic Disease of the Femur
Journal of the American Academy of Orthopaedic Surgeons
58
ing the primary site of malignancy
in 26 (65%) patients.
Evaluation of skeletal metastases
is usually accomplished with one or
more of four clinical imaging meth-
ods: plain-film radiography, radio-
isotope scanning, CT, and magnetic
resonance (MR) imaging. Radio-
graphic evaluation should involve
not only spot orthogonal views of
the affected region but also a sur-

vey with anteroposterior and lateral
radiographs of the entire femur.
Care must be taken to avoid miss-
ing metachronous lesions, which
may influence the choice of treat-
ment and may ultimately compro-
mise outcome.
Metastatic lesions originating
from the lung (Fig. 1), kidney, and
thyroid are commonly lytic in ap-
pearance. Lesions of prostatic ori-
gin are usually blastic. Breast carci-
nomas are commonly mixed in
appearance. Most metastatic lesions
arise from within the intramedullary
canal. In rare instances, aggressive
vascular tumors are intracortical,
whereas squamous cell carcinoma of
the lung may be juxtacortical. Bone
lesions in patients more than 40
years old are more likely to be sec-
ondary to metastatic lesions and
myeloma, but bone lesions in
patients less than 40 years old are
more likely to be related to infection
and primary tumors of bone.
14
Lod-
wick
15

described three patterns of
bone destruction: geographic le-
sions (solitary, well-defined lesions
with sharply demarcated borders,
seen in the most slowly developing
metastases), Òmoth-eatenÓ lesions
(multiple small lytic areas in spongy
and cortical bone with ill-defined
margins), and permeative lesions
(multiple tiny lytic areas in princi-
pally cortical bone, found in the
most aggressive lesions).
Patients presenting for ortho-
paedic evaluation of impending or
pathologic fracture of the femur
usually have a prior history of a
malignant condition. If a patient
has a history of skeletal or visceral
metastasis and a lesion of the fe-
mur consistent with metastatic dis-
ease, rarely is a study other than
high-quality orthogonal radiogra-
phy of the entire femur necessary.
However, in the case of lesions in
either of the femoral condyles, the
femoral head, or the acetabulum,
CT may be necessary to assess the
degree of bone destruction. Fur-
thermore, if there is reason to eval-
uate the amount of involvement of

the femur or if it is suspected that a
large soft-tissue mass may be asso-
ciated with a bone lesion (as may
occur in renal cell carcinoma or
squamous cell carcinoma), MR im-
aging may be helpful.
One must be cautious about
plain-film radiographic evaluation
of a solitary osseous lesion consis-
tent with metastatic disease in a pa-
tient with a remote history of a prior
malignant condition (>5 years) but
without prior evidence of distant
metastases. The possibility of a sec-
ond primary tumor or even a sar-
coma of bone or soft tissue should
always be considered, especially if
Figure 1 Anteroposterior (A) and lateral (B) radiographs of the knee reveal large destructive lesion of the distal femur due to metastatic
disease originating in the lung. C and D, Radiographs obtained after prophylactic stabilization with a dynamic compression screwÐplate
device augmented with methylmethacrylate.
A B C D
Kyle C. Swanson, MD, et al
Vol 8, No 1, January/February 2000
59
the radiologic characteristics are not
consistent with metastases from the
primary tumor. Obtaining a biopsy
prior to or at the time of surgery
should be considered to confirm the
diagnosis.

Further imaging is warranted if
there is a prior history of malignancy
coupled with symptoms suggestive
of metastatic disease, even when
radiographs appear normal. Edel-
styn et al
16
demonstrated that more
than 50% of the medullary canal
must be destroyed before a meta-
static lesion is visualized on plain
films. Radionuclide scanning with
technetium-99m methylene diphos-
phonate is an extremely sensitive
modality for detecting skeletal
lesions. A period of 2 to 18 months
may be necessary before a lesion
initially evident on radionuclide
scanning becomes apparent on
plain-film radiography.
17
The
main disadvantage of bone scintig-
raphy is its lack of specificity; find-
ings must always be correlated
with further imaging.
Treatment Strategy
General Considerations
The management goals of treat-
ment of metastatic disease of the

femur are relief of pain and resto-
ration of premorbid ambulatory
function. Recognition of the full
therapeutic potential for each
patient requires a multidisciplinary
team approach.
The decision between operative
and nonoperative management is
determined on the basis of the loca-
tion, tumor type, and extent of the
tumor and the patientÕs general med-
ical condition (Fig. 2). The initial
step in a rational approach to im-
pending or established pathologic
fractures of the femur is to carefully
examine the patient and to deter-
mine the overall health status. If
there is no reasonable expectation
that the patient can survive a major
operative procedure, nonsurgical
measures may be the only viable
alternative for palliation. If the
patient can reasonably be expected
to survive the procedure but will
have an extremely limited potential
for survival beyond a few weeks, it
may not be prudent to proceed with
an operative procedure. Patients
who are not expected to survive long
enough to recover and truly benefit

from surgical treatment may decide
against committing to the time, dis-
comfort, and expense of proceeding
with an operation and may instead
prefer palliative measures, such as
analgesic medications or splinting.
Although the latter approach would
probably restrict the patient to bed
and chair, it might be appealing to
someone who is aware of his or her
short life expectancy.
Pathologic Fracture
If the patient is deemed to be
healthy enough and the life expec-
tancy is such that there will be suf-
ficient benefit (e.g., pain relief, ease
of mobility, ease of care) to justify
the procedure, an operative ap-
proach might be appropriate. After
assessment of the general health
status, the next step is to evaluate
local tumor factors. If the patient
has a pathologic fracture secondary
to metastatic disease, local factors
must be addressed when planning
treatment.
In most cases, the surgeon should
concentrate on achieving stable fixa-
tion (Figs. 1 and 3), with the expec-
tation that local control of the

metastatic disease can be obtained
without resection of the tumor. This
is true of most metastatic lesions,
especially those due to primary
tumors in the breast or prostate.
However, some metastatic lesions
are relatively resistant to adjunctive
treatments, such as radiation therapy,
chemotherapy, and hormonal ma-
nipulation. For example, there are
few chemotherapy options for
hypernephromas, which are also
particularly unresponsive to radia-
tion therapy. In instances in which
there is considerable bone destruc-
tion, fracture fixation and postoper-
ative radiation therapy do not ade-
quately control the tumor, and
Not a surgical
candidate
Palliative
treatment
Possible surgical
candidate
Impending
fracture
Low risk
of fracture
Palliative
treatment

High risk
of fracture
Established
fracture
General health
status
Resection or fixation
± adjuvant treatment
Resection or fixation
± adjuvant treatment
Figure 2 Treatment strategy for patients with metastatic disease of the femur.
Surgical Treatment of Metastatic Disease of the Femur
Journal of the American Academy of Orthopaedic Surgeons
60
tumor progression leads to ultimate
failure of the fixation (Fig. 4). Be-
cause patients with hypernephroma
may have a relatively prolonged
survival, particularly if there is only
one site of metastatic disease, it may
be better to resect the involved area
of bone and perform a prosthetic
reconstruction, rather than relying
on internal fixation and adjuvant
radiation treatment. In addition to
dealing with the fracture, resection
of a solitary metastasis may im-
prove the patientÕs chances of sur-
vival. This strategy is applicable to
other tumors that are resistant to

radiation therapy or are prone to
recurrence. Preoperative emboliza-
A B C D
Figure 3 Anteroposterior radiographs of the femur demonstrate pathologic subtrochanteric fracture (A) and impending distal femur
fracture (B). C and D, Anteroposterior radiographs obtained after stabilization with an intramedullary nail.
A B C
Figure 4 A, Anteroposterior radiograph of the proximal femur 2 years after intramedullary fixation of an impending pathologic fracture
due to metastatic renal cell carcinoma. Despite radiation therapy, there was progression of the lesion with extensive cortical bone loss.
B, Extensive vascularity of the lesion necessitated preoperative embolization. C, Anteroposterior radiograph obtained after proximal
femoral replacement arthroplasty.
Kyle C. Swanson, MD, et al
Vol 8, No 1, January/February 2000
61
tion of highly vascular lesions may
minimize the risk of massive hem-
orrhage during surgery.
The size and extent of the tumor
are also important factors that must
be carefully assessed when plan-
ning an operative procedure. In ad-
dition to plain radiography, MR
imaging may provide helpful infor-
mation regarding intramedullary
involvement, as well as any soft-
tissue extension of the tumor. A CT
scan may reveal the extent of corti-
cal disruption. Technetium scan-
ning or MR imaging may suggest
the possibility of additional lesions
in the same bone. However, in the

case of highly aggressive lesions or
multiple myeloma, the Tc-99m
bone scan may not be positive.
Impending Pathologic Fracture
If the patient is known to have
metastasis to the femur but there is
no actual fracture, the surgeon
needs to assess the relative risk of
fracture. The type, extent, size, and
location of the tumor are all factors
in determining the risk of fracture.
Lytic lesions are more likely to frac-
ture than blastic lesions. Large
tumors, those that have soft-tissue
extension, and those that occur in
the region of the lesser trochanter
of the femur are particularly prone
to fracture.
There have been several attempts
to provide guidelines for assessing
the risk of fracture in the presence of
metastasis.
18-21
Although it must be
borne in mind that estimating the
risk of pathologic fracture is very
subjective and is dependent on
many variables (e.g., location of
lesion, quality of host bone, and
anticipated load), the Mirels scoring

system has proved useful (Table 1).
The location of the lesion, the
degree of pain, the type of bone
destruction, and the size of the
defect are the variables considered
in this 12-point scoring system. A
score of 9 or above indicates a high
likelihood of subsequent fracture.
In addition to the Mirels system,
several general rules regarding
involvement of the femur may be
helpful. Even small lesions in the
region of the lesser trochanter are
particularly at risk for fracture.
Most lesions in the subtrochanteric
area are also at high risk, especially
when the metastasis is on the medial
aspect of the bone. In diaphyseal
lesions, destruction of 50% of the
diameter or one cortex, as evi-
denced radiographically, is proba-
bly a valid predictor of subsequent
fracture. Pain, particularly with
weight bearing, in a lytic focus fol-
lowing radiation therapy is a solid
indication for prophylactic stabi-
lization despite the radiographic
appearance.
Although there are guidelines
and methods of systematic assess-

ment, there is really no accurate
way to predict the risk of fracture.
Even experienced orthopaedic sur-
geons will occasionally underesti-
mate the risk of pathologic fracture.
If there is a high risk of fracture
and the patientÕs general condition
warrants an operative approach, an
appropriate procedure can be select-
ed and planned. Preoperatively, the
patient will need to protect the
femur with ambulation aids to mini-
mize the chance of a fracture occur-
ring before the procedure.
Preoperative Planning
Metastatic lesions to the femur
present unique challenges, but the
treatment principles are the same
regardless of location. A construct
should ideally provide enough stability to
allow immediate
full weight bearing with
enough durability to last the patientÕs
expected lifetime. In addition, all areas
of weakened bone should be ad-
dressed at the time of the operation
in anticipation of disease progres-
sion. To minimize disease progres-
sion and possible failure of the im-
plant or internal fixation, radiation

should be administered postopera-
tively, preferably to the entire femur.
Operative Procedures by
Site
Femoral Head and Neck
Fractures
Both impending lesions and
complete pathologic fractures of
the femoral head and neck should
be managed with replacement ar-
throplasty (Fig. 5). The high stresses
across the proximal femur, com-
bined with the limited potential for
healing, even in low-demand pa-
tients, has resulted in a high rate of
failure for internal fixation devices.
Moreover, fractures in tumor-
destroyed bone in the femoral neck
Table 1
Mirels Scoring System for Assesing Risk of Pathologic Fracture in Long
Bones
*
Score
Variable 1 2 3
Site Upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion type Blastic Mixed Lytic
Size (as a proportion <1/3 1/3 - 2/3 >2/3
of shaft diameter)
*

Reproduced with permission from Mirels H: Metastatic disease in long bones: A pro-
posed scoring system for diagnosing impending pathologic fractures. Clin Orthop
1989;249:256-264.
Surgical Treatment of Metastatic Disease of the Femur
Journal of the American Academy of Orthopaedic Surgeons
62
(even nondisplaced fractures) will
rarely heal within the patientÕs
remaining life span.
There have been several reports
of favorable results with prosthetic
replacement.
22,23
Lane et al
24
re-
ported the results in 167 patients
treated by endoprosthetic replace-
ment for impending or complete
pathologic fractures of the hip. All
patients reported dramatic relief of
pain. Use of a long-stemmed fe-
moral endoprosthesis or a total
prosthetic hip resulted in significant
enhancement of the ambulatory sta-
tus in three fourths of those who
were able to walk before the frac-
ture. Nonwalkers improved in their
ability to transfer. The patients who
had little benefit from the procedure

were those who were bedridden,
usually with severe metastatic in-
volvement of the spine.
Patients with proximal femoral
lesions may have concurrent ace-
tabular lesions. Harrington
25
has
classified acetabular metastatic
lesions into four groups on the
basis of location, extent of involve-
ment, and surgical technique re-
quired to accomplish acetabular
reconstruction. Unless tumor in-
volvement is extensive, creating
structural weakness in the acetabu-
lum, a standard cemented bipolar
hemiarthroplasty or hip replace-
ment may be utilized. The choice of
hemiarthroplasty versus total hip
arthroplasty is dependent on the
condition of the acetabular cartilage
and the extent of involvement.
Harrington
26
has reported a compli-
cation rate of less than 1% for endo-
prosthetic migration due to weak-
ened periacetabular bone.
In lesions that extend distally into

the region of the lesser trochanter, a
calcar-replacing prosthesis may be
utilized. Multiple lesions in the
peritrochanteric and diaphyseal
regions of the femur, as well as rela-
tively radiation therapyÐresistant
lesions, are often best addressed
with a long-stemmed prosthesis to
prophylactically reinforce the fe-
mur and avoid stress risers, espe-
cially in patients with potentially
long survival who are prone to
multiple lesions, such as myeloma.
Additionally, if there is thought to
be significant risk that distal lesions
will develop in the patientÕs re-
maining life span despite radiation
therapy, use of a long-stemmed
prosthesis may be indicated.
Intertrochanteric Fractures
The surgical treatment of patho-
logic intertrochanteric fractures
remains controversial. Lesions con-
fined to the intertrochanteric region,
with minimal medial cortical-bone
destruction, have traditionally been
treated with a compression screw or
nail plate. However, prolonged sur-
vival, local disease progression,
poor initial fixation, delayed union

or nonunion, and lack of load shar-
ing between the implant device and
residual bone have all contributed
to a high failure rate with this form
of treatment (Fig. 6).
Proponents of the use of open
reduction and internal fixation
with a compression screw or nail-
plate device stress the importance
of adjunctive stabilization with
methylmethacrylate. A cortical
window is created in the lateral
cortex, and all devitalized tumor-
laden tissue is removed. Whether
the compression screw should be
inserted before or after injection of
methylmethacrylate into the bone
is controversial. Some surgeons
have chosen to hollow out the
femoral head and neck by drilling
to the subchondral bone. Cement
of liquid consistency is then placed
in the defect, and the compression
screw is placed in the cement.
Advocates argue that the screw is
thus embedded in cement rather
than in bone of questionable in-
tegrity. The combination of screw
threads and cement gives a greater
Figure 5 A, Anteroposterior radiograph of the proximal femur shows a pathologic frac-

ture of the femoral neck. B, Anteroposterior radiograph obtained after bipolar hemiarthro-
plasty.
A B
Kyle C. Swanson, MD, et al
Vol 8, No 1, January/February 2000
63
surface area of contact for the fixa-
tion device in the femoral head and
thus reduces the risk of the screw
cutting out of the femoral head.
Critics state that drilling of the
femoral head may result in osteo-
necrosis or release of microemboli
of cement into the rich vascular
plexus in the head of the femur.
Adjunctive stabilization by inject-
ing methylmethacrylate distally
into the medullary canal can also
add stability to the cortical screws
along the side plate. The cortical
screws are then inserted by drilling
and tapping both the bone and the
methylmethacrylate.
Intramedullary hip screws have
recently been used for pathologic
intertrochanteric fractures. These
devices have the biomechanical
advantage of more medial place-
ment closer to the compression side
of the femur and away from the

lateral-tension side. However,
short intramedullary hip screws
have been problematic because of
fractures occurring at the tip of the
nail in the diaphyseal region. Long
intramedullary hip screws have the
advantage of protecting the entire
bone, but there have been few
reports on their use. Another suc-
cessful alternative includes the use
of an intramedullary rod with
proximal fixation screws that ex-
tend into the femoral neck and
head, with distal interlocking.
Extensive involvement of the
femoral head and neck with exten-
sion into the trochanteric and sub-
trochanteric regions is seldom
managed successfully with internal
fixation devices. Prosthetic replace-
ment with either calcar or proximal
femoral devices is the procedure of
choice for large destructive areas
not amenable to internal fixation,
for salvage of failed internal fixa-
tion, and for lesions not amenable
to radiation therapy. Ease of appli-
cation and improvements in im-
plant design and availability have
contributed to more frequent use of

these devices. Potential disadvan-
tages include increased rates of
postoperative infection and disloca-
tion. With use of proximal femurÐ
replacing prostheses, loss of hip
flexor and abductor strength re-
sults in permanent gait distur-
bance. Despite the high complica-
tion rate, patients may be allowed
immediate weight bearing with
predictable relief of pain. Use of
the bipolar femoral component and
modular design has helped reduce
the incidence of complications due
to improper soft-tissue tension and
dislocation.
Subtrochanteric Fractures
Subtrochanteric fractures are pri-
marily treated with intramedullary
devices. The region extending 5 cm
distally from the lesser trochanter
receives tremendous torque and
shear stress, resulting in high rates
of failure with screw and side-plate
devices. The Zickel nail was previ-
ously used to treat complete and
impending pathologic fractures in
the subtrochanteric region (Fig. 7).
Its design allowed stable fixation
between the proximal and distal

fragments. Zickel and Mouradian
27
reported successful results in the
treatment of 35 pathologic impend-
ing and complete fractures in the
subtrochanteric region. Early mobi-
lization or ambulation was achieved
in nearly all cases.
Insertional difficulty, proximal
fragment fracture, femoral shorten-
ing, varus migration, and rotational
instability associated with the
Zickel nail have been addressed by
the current use of reconstruction
A B
Figure 6 A, Anteroposterior radiograph of the proximal femur demonstrates a large
destructive lesion of the peritrochanteric region stabilized with a compression screwÐplate
device. B, Anteroposterior radiograph obtained 1 year after internal fixation shows pro-
gressive collapse and failure of the internal fixation.
Surgical Treatment of Metastatic Disease of the Femur
Journal of the American Academy of Orthopaedic Surgeons
64
intramedullary nails (Fig. 3). Se-
cure fixation may be obtained with
two screws directed proximally
into the femoral head. Likewise,
the nail should be statically locked
with two distal screws. Methyl-
methacrylate can be used as an
adjunct to fixation, but is not neces-

sary in most cases, due to the in-
trinsic strength of the device.
Recently, so-called third-genera-
tion variations of the reconstruc-
tion nail have become available. A
feature of these devices in common
with early reconstruction-nail de-
signs is the capability for proximal
and distal interlocking. However,
these devices differ primarily in the
proximal interlocking device. The
spiral-blade nail uses a single low-
profile spiral-blade device to secure
proximal fixation while conserving
bone loss in the femoral neck. In
many cases, these nails have been
placed without reaming, thus di-
minishing blood loss.
The use of modular proximal
femoral replacement prostheses
should be reserved for radiation
therapyÐresistant lesions with
extensive involvement of the head,
neck, and peritrochanteric femur
for which stable proximal screw
fixation is unattainable (Fig. 4). In
selected patients with a solitary
metastasis and overall favorable
prognosis, reconstruction with an
allograft-prosthetic composite may

also be a consideration. There is no
role for condylocephalic or Ender
nails because of the high rate of
mechanical failure.
Diaphyseal Fractures
Impending pathologic fractures
of the femoral shaft can usually be
treated by conventional closed in-
tramedullary rodding techniques.
The use of reconstruction nails,
locked proximally and distally, has
served to reduce the common com-
plication of progressive femoral
collapse with telescoping of the
fracture fragments and proximal
migration of the rod. With tumor
progression, proximal placement of
screws into the femoral head offers
more secure fixation than conven-
tional transverse or antegrade
screw placement and may protect
the femoral head from subsequent
fracture. Open rodding techniques
may be necessary for large defects
with extensive cortical destruction.
Exposure of the lesion, curettage,
and augmentation of the lesion
with methylmethacrylate may be
necessary to prevent collapse.
Distal Femur Fractures

Pathologic fractures in the supra-
condylar and condylar regions of
the femur are unusual and difficult
to treat. If there is sufficient bone
stock, use of conventional internal
fixation devices augmented with
methylmethacrylate will usually
achieve stability. Satisfactory pain
relief and restoration of ambulatory
function have been achieved with
nail-plate and dynamic compression
screwÐplate devices (Fig. 1). Use of
the Zickel supracondylar nail has
reportedly been a successful treat-
ment option for fractures in the
supracondylar region.
28
Treatment
with internal fixation devices is gen-
erally not recommended or possible
for patients with poor bone stock or
with massive destruction of the
femoral condyles. Modular-type
distal femoral knee arthroplasty has
also been successful in achieving
immediate stability and full weight-
bearing status.
Summary
In recent years, there have been
marked improvements in tech-

niques for achieving secure fixation
of pathologic fractures of the femur
or prosthetic reconstruction, even
in cases of severe tumor destruc-
tion. Careful preoperative plan-
ning is essential to determine the
extent of tumor involvement and to
select appropriate reconstruction
and implant type. Achievement of
stable, durable fixation or prosthet-
ic replacement will improve the
quality of life for patients with
these fractures.
Figure 7 A, Anteroposterior radiograph reveals a pathologic subtrochanteric fracture sec-
ondary to lung cancer. B, Stabilization with a Zickel nail augmented with methyl-
methacrylate.
A B
Kyle C. Swanson, MD, et al
Vol 8, No 1, January/February 2000
65
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